Teens and young adults should be started on long-acting reversible contraceptives before sexual activity commences: AGAINST: Pre-emptive use without need or benefit may cause more harm than good.

Abstract

Do the benefits outweigh the risks of starting a contraceptive method prior to sexual debut? Likely that depends on how soon the debut might occur following method initiation. In order to prove my point, let's deal in extremes and discuss initiating a long acting reversible contraceptive (LARC) method ‘pre-emptively’ and remote from sexual debut, as opposed to ‘proactively’—such as a young woman with an inkling that her first sexual experience may be soon (e.g. school dance, parents out of town, a boyfriend with a car—I could go on but I think you get the point). I will focus my argument around the ‘pre-emptive’ initiation of LARC, as the proactive prevention of pregnancy is a proven public health strategy. ‘Pre-emptive’ use of LARC in a young woman who gains additional health benefits from the method is entirely reasonable. Most clinicians including myself rely on noncontraceptive benefits for the treatment of dysmenorrhoea, irregular bleeding, menstrual migraines, etc. However, we are dealing in hyperbole here and must assume that our young woman in question has no other reason to use LARC. We expose her to the risk of use when she has no immediate need and receives no additional benefits. Although LARC methods are extremely safe, severe adverse events can occur, e.g. Copper T: heavy menstrual bleeding; intrauterine device (IUD): perforation, infection; implant: infection, deep placements; or injections: allergic reactions. The more worrisome issue for me, however, is the side effects and/or the bad placement events that a young woman may experience which can bias her forever against LARC use. Nulliparity and/or young age has been associated with higher rates of failed insertion (Dermish AI, et al. Contraception 2012;87:182–6) and more pain with placement (Brockmeyer A, et al. Eur J Contracep Reprod Health Care 2008;13:248–54) as well as ongoing pain, cited as a major reason for removal (Suhonen S, et al. Contraception 2004;69:407–12). Irregular bleeding in addition to perceived or actual weight gain and acne is attributed to hormonal-LARC methods, especially depot medroxyprogesterone acetate (DMPA), which could influence dissatisfaction and discontinuation. Although discontinuation rates are low with most LARC methods used for contraception (not so for DMPA), this may not be true in a woman using LARC for no reason. As LARC methods are 20 times more effective than short acting methods and the typical failure rates of short acting methods in teens and young women has recently been shown to be worse than realised (18%) (Secura GM, et al. N Engl J Med 2014;371:1316–23) I want to ensure that women have a positive view of these methods. Finally, would a young woman independently choose to use LARC when she has no need and gain no benefit, or is she being coerced? As a huge supporter and provider of LARC to teens and young women, I recognise that LARC methods are incredibly important tools in our fight to prevent unplanned pregnancies as well as their extensive non-contraceptive benefits. However ‘pre-emptive’ use without eminent need or benefit may cause more harm than good. Full disclosure of interests available to view online as supporting information.